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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547203524
Report Date: 03/28/2022
Date Signed: 03/28/2022 01:48:25 PM

Document Has Been Signed on 03/28/2022 01:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:BAXTER ADULT RESIDENTIALFACILITY NUMBER:
547203524
ADMINISTRATOR:BAXTER, LISA & JAMESFACILITY TYPE:
735
ADDRESS:860 GERRY LANETELEPHONE:
(559) 781-9288
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 6CENSUS: 6DATE:
03/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:08 PM
MET WITH:Christopher BaxterTIME COMPLETED:
01:59 PM
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On 3/28/22, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required inspection visit. LPA Medina met with Chiristopher Baxter and discussed purpose of the visit. .

LPA Medina toured the facility with the Licensee, no residents present at time of inspection. Visitor log-in temperature check was observed at entry. Hand sanitizer readily available to residents and visitors. Facility has one entrance/exit point for staff and residents. Facility staff was observed wearing masks.

LPA observed a two day supply of perishable food and seven day supply of non-perishable food on site. Fire extinguisher has a service date of 4/28/21. Carbon monoxide detectors and smoke detectors present and observed operational during inspection.

LPA observed plan for COVID-19 mitigation and infection control. Resident files have updated emergency contact information. LPA observed the following supply of personal protective equipment: gloves, gowns, masks and hand sanitizer.

No deficiencies were cited. Exit interview was conducted with the Licensee and a copy of this report was signed on site and will be provided to Licensee by e-mail.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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